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Initial Intake Form
First name
*
Last name
*
Email
Address
*
Birthday
*
Year
Month
Day
Phone
*
Can we leave a voicemail at this number?
*
Yes
No
Gender (M/F/O)
Allergies
*
Emergency contact
*
Emergency contact Phone Number
*
Emergency contact address
*
In a few sentences please explain why you are seeking out counselling services.
*
How long has this problem been going on for? What have you already tried in attempt to help improve your situation?
*
Have you seen a counsellor in the past? If so, what was helpful about your past experience? Was anything unhelpful?
*
What are your counselling goals? What do you hope counselling helps to improve?
*
Which counselling service are you wanting to be connected to:
*
Adult (18+)
Adolescent (12-17)
Children Services (6-11)
Coaching Services
How would you like to receive services?
*
In-person
Telephone
Virtual video
Is there anything else I should know about you, or that you would like to share with me?
Submit
Please help me get to know a little bit about you and your reason for seeking services.
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